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 THIRD EDITION

Rosado-de-Christenson
Martínez-Jiménez
Restrepo | Betancourt-Cuellar
Carter | Lichtenberger
Heeger | Ternes
Carrillo-Bayona | Frazier
Silva | Garrana
Alegría | Fuss
ii
 THIRD EDITION

Melissa L. Rosado-de-Christenson, MD, FACR

Section Chief, Thoracic Radiology
Department of Radiology
Saint Luke's Hospital of Kansas City
Professor of Radiology
University of Missouri-Kansas City School of Medicine
Kansas City, Missouri

Santiago Martínez-Jiménez, MD
Department of Radiology
Saint Luke's Hospital of Kansas City
Professor of Radiology
University of Missouri-Kansas City School of Medicine
Kansas City, Missouri

iii
 Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

DIAGNOSTIC IMAGING: CHEST, THIRD EDITION ISBN: 978-0-323-79663-7

Inkling: 978-0-323-79664-4
Copyright © 2022 by Elsevier. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,
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arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be
found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as
may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds or experiments described herein.
Because of rapid advances in the medical sciences, in particular, independent verification of
diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is
assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or
property as a matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.

Previous edition copyrighted 2012.

Library of Congress Control Number: 2021944546

Printed in Canada by Friesens, Altona, Manitoba, Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

iv
 Dedications
To my wonderful family – Paul, Jennifer, Heather, David, Mike, and Juniper,
for your unconditional love and support. You are everything to me.

MLR

To Isabela and Lucas. You are simply the best. Just keep smiling and
remember that monsters were never under the bed.

SMJ

v
 Contributing Authors
Carlos S. Restrepo, MD
Professor of Radiology
Director of Cardiothoracic Imaging
Department of Radiology
The University of Texas
Health Science Center at San Antonio
San Antonio, Texas
Sonia L. Betancourt-Cuellar, MD
Professor of Thoracic Imaging
Department of Thoracic Imaging
The University of Texas MD Anderson Cancer Center
Houston, Texas
Brett W. Carter, MD, CPPS
Director of Clinical Operations
Chief Patient Safety and
Quality Officer, Diagnostic Imaging
Professor of Thoracic Imaging
The University of Texas MD Anderson Cancer Center
Houston, Texas
John P. Lichtenberger, III, MD
Chief of Thoracic Imaging
Associate Professor of Radiology
Department of Radiology
George Washington University Medical
Faculty Associates
Washington, D.C.
Allen Heeger, DO
Thoracic Radiologist
West County Radiological Group
Mercy Hospital
St. Louis, Missouri
Tyler H. Ternes, MD
Section Chief, Thoracic Imaging
Clinical Assistant Professor
University of Kansas School of Medicine
Wichita Diagnostic Radiology
Wichita, Kansas
vi
Jorge Alberto Carrillo-Bayona, MD
Professor of Radiology
Universidad Nacional de Colombia
Hospital Universitario Mayor Mederi
RIMAB
Bogotá, Colombia
Aletta Ann Frazier, MD
Section Chief, Cardiothoracic Imaging
ACR Institute for Radiologic Pathology (AIRP)
Silver Spring, Maryland
Professor of Diagnostic Radiology
University of Maryland School of Medicine
Baltimore, Maryland
Claudio Silva, MD, MSc, MBA
Associate Professor of Radiology
Clínica Alemana - Universidad del Desarrollo
School of Medicine
Cardiothoracic Imaging Division, Radiology Department
Clínica Alemana de Santiago
Santiago, Chile
Sherief H. Garrana, MD
Assistant Professor of Radiology
Department of Radiology
Saint Luke’s Hospital of Kansas City
University of Missouri-Kansas City School of Medicine
Kansas City, Missouri
Julia Alegría, MD
Chief, Cardiothoracic Imaging Division
Radiology Department
Clínica Alemana de Santiago
Santiago, Chile
Assistant Professor of Radiology
Clínica Alemana - Universidad del Desarrollo School of
Medicine
Cristina Fuss, MD
Associate Professor and Section Chief
Cardiothoracic Imaging
Department of Diagnostic Radiology
Oregon Health & Science University
Portland, Oregon
Additional Contributing Authors
Gerald F. Abbott, MD, FACR
Jonathan Hero Chung, MD
Florian J. Fintelmann, MD, FRCPC
Tomás Franquet, MD, PhD
Terrance Healey, MD
Laura E. Heyneman, MD
Jeffrey P. Kanne, MD
Kyung Soo Lee, MD
Diane C. Strollo, MD, FACR
Christopher M. Walker, MD
Helen T. Winer-Muram, MD
Carol C. Wu, MD

vii
 Preface
We proudly present the 3rd edition of Diagnostic Imaging: Chest. It is hard to believe
that 9 years have elapsed since the publication of the 2nd edition. I am immensely
grateful to the Elsevier team for giving me the opportunity to, once again, serve as
lead author of this work, and to my good friend, colleague, and practice partner, Dr.
Santiago Martínez-Jiménez, for serving as co-lead author.

The 3rd edition is similar to the 2nd in both style and appearance, with a succinct,
bulleted text format and image-rich depictions of a large number of cardiothoracic
diseases. The content is organized based on both anatomic location and category of
disease. The work is enhanced by a wealth of new material that includes:

• 13 updated and illustrated section introductions that set the stage for
the specific diagnoses that follow
• Updated sections that define and illustrate thoracic imaging terminology,
including many entities from the Fleischner Society glossary of terms, as well
as classic signs in chest imaging
• An updated section on posttreatment changes in the thorax and the
effects of novel therapies that include surgery, radiotherapy, chemotherapy,
immunotherapy, and ablation procedures
• New chapters on emerging diseases, including coronavirus disease-2019
(COVID-19) and e-cigarette or vaping product use-associated lung injury
(EVALI)
• A total of 344 chapters supplemented with updated material and references
• In all, 2,640 images and 2,536 online-only images that include radiographic,
CT,
MR, and PET/CT images, as well as gross photographs and
photomicrographs where appropriate
• Updated graphics that illustrate the anatomic/pathologic basis of various
imaging abnormalities

We were fortunate to recruit a world-class team of authors who delivered

meticulously researched content in all areas of thoracic imaging, including both
seasoned authors from the 2nd edition and promising early-career cardiothoracic
radiologists destined to lead this project in the future. We were privileged to work
with Terry W. Ferrell, MS, an outstanding lead editor whose suggestions and edits
enhanced each and every chapter, and with Lane R. Bennion, MS, a gifted medical
illustrator whose artistry greatly enriched the imaging content. We gratefully
acknowledge the tireless work of the Elsevier production staff, who sustained us
through each step of the work. Finally, we express our heartfelt gratitude to Karen
E. Concannon, PhD, senior manager of content, for her enthusiastic leadership and
thoughtful guidance through the entire process.

viii
Melissa L. Rosado-de-Christenson, MD, FACR
Section Chief, Thoracic Radiology
Department of Radiology
Saint Luke's Hospital of Kansas City
Professor of Radiology
University of Missouri-Kansas City School of Medicine
Kansas City, Missouri

ix
x
Acknowledgments
LEAD EDITOR
Terry W. Ferrell, MS

LEAD ILLUSTRATOR
Lane R. Bennion, MS

TEXT EDITORS
Arthur G. Gelsinger, MA
Rebecca L. Bluth, BA
Nina Themann, BA
Megg Morin, BA
Kathryn Watkins, BA

ILLUSTRATIONS
Richard Coombs, MS
Laura C. Wissler, MA

IMAGE EDITORS
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS

ART DIRECTION AND DESIGN

Tom M. Olson, BA

PRODUCTION EDITORS
Emily C. Fassett, BA
John Pecorelli, BS

xi
xii
 Sections
SECTION 1:
Overview of Chest Imaging

SECTION 2:
Developmental Abnormalities

SECTION 3:
Airway Diseases

SECTION 4:
Infections

SECTION 5:
Pulmonary Neoplasms

SECTION 6:
Interstitial, Diffuse, and Inhalational Lung Disease

SECTION 7:
Connective Tissue Disorders, Immunological Diseases, and Vasculitis

SECTION 8:
Mediastinal Abnormalities

SECTION 9:
Cardiovascular Disorders

SECTION 10:
Trauma

SECTION 11:
Post-Treatment Chest

SECTION 12:
Pleural Diseases

SECTION 13:
Chest Wall and Diaphragm

xiii
 TABLE OF CONTENTS

26 Peribronchovascular
SECTION 1: OVERVIEW OF CHEST Santiago Martínez-Jiménez, MD
IMAGING 27 Perilobular Pattern
INTRODUCTION AND OVERVIEW Santiago Martínez-Jiménez, MD
28 Perilymphatic
4 Approach to Chest Imaging Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 29 Pneumatocele
Melissa L. Rosado de Christenson, MD, FACR
ILLUSTRATED TERMINOLOGY 30 Reticular Pattern
6 Approach to Illustrated Terminology Melissa L. Rosado de Christenson, MD, FACR
Melissa L. Rosado de Christenson, MD, FACR 31 Secondary Pulmonary Lobule
8 Acinar Nodules Melissa L. Rosado de Christenson, MD, FACR
Melissa L. Rosado de Christenson, MD, FACR and Tyler H. 32 Traction Bronchiectasis
Ternes, MD Melissa L. Rosado de Christenson, MD, FACR
9 Air Bronchogram 33 Tree-in-Bud Opacities
Tyler H. Ternes, MD Melissa L. Rosado de Christenson, MD, FACR
10 Air-Trapping
Tyler H. Ternes, MD CHEST RADIOGRAPHIC AND CT SIGNS
11 Airspace 34 Approach to Chest Radiographic and CT Signs
Tyler H. Ternes, MD Santiago Martínez-Jiménez, MD
12 Architectural Distortion 40 Air Crescent Sign
Tyler H. Ternes, MD Santiago Martínez-Jiménez, MD
13 Bulla/Bleb 41 Cervicothoracic Sign
Tyler H. Ternes, MD Santiago Martínez-Jiménez, MD
14 Cavity 42 Comet Tail Sign
Melissa L. Rosado de Christenson, MD, FACR Santiago Martínez-Jiménez, MD
15 Centrilobular 43 CT Halo Sign
Santiago Martínez-Jiménez, MD and Melissa L. Rosado de Santiago Martínez-Jiménez, MD
Christenson, MD, FACR 44 Deep Sulcus Sign
16 Consolidation Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 45 Fat Pad Sign
17 Cyst Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 46 Finger-in-Glove Sign
18 Ground-Glass Opacity Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 47 Hilum Convergence Sign
19 Honeycombing Santiago Martínez-Jiménez, MD
Santiago Martínez-Jiménez, MD 48 Hilum Overlay Sign
20 Interlobular Septal Thickening Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 49 Incomplete Border Sign
21 Intralobular Lines Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 50 Luftsichel Sign
22 Mass Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 51 Reversed Halo Sign
23 Miliary Pattern Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 52 Rigler and Cupola Signs
24 Mosaic Attenuation Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 53 S-Sign of Golden
25 Nodule Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 54 Signet Ring Sign
Santiago Martínez-Jiménez, MD

xiv
 TABLE OF CONTENTS
55 Silhouette Sign
Santiago Martínez-Jiménez, MD
SYSTEMIC CIRCULATION
110 Accessory Azygos Fissure
ATELECTASIS AND VOLUME LOSS Sherief H. Garrana, MD
56 Approach to Atelectasis and Volume Loss 112 Azygos and Hemiazygos Continuation of the IVC
Melissa L. Rosado de Christenson, MD, FACR and Gerald F. Sherief H. Garrana, MD
Abbott, MD, FACR 116 Persistent Left Superior Vena Cava
60 Atelectasis Claudio Silva, MD, MSc, MBA
Tomás Franquet, MD, PhD 120 Aberrant Subclavian Artery
64 Cicatricial Atelectasis Sherief H. Garrana, MD
Brett W. Carter, MD, CPPS 122 Right Aortic Arch
65 Rounded Atelectasis Santiago Martínez-Jiménez, MD
Brett W. Carter, MD, CPPS 126 Double Aortic Arch
Carlos S. Restrepo, MD and Diane C. Strollo, MD, FACR
SECTION 2: DEVELOPMENTAL 130 Aortic Coarctation
ABNORMALITIES Tyler H. Ternes, MD and Santiago Martínez-Jiménez, MD

INTRODUCTION AND OVERVIEW CARDIAC, PERICARDIAL, AND VALVULAR

DEFECTS
68 Approach to Developmental Abnormalities
Melissa L. Rosado de Christenson, MD, FACR 134 Atrial Septal Defect
Brett W. Carter, MD, CPPS
AIRWAYS 138 Ventricular Septal Defect
70 Tracheal Bronchus and Other Anomalous Bronchi Brett W. Carter, MD, CPPS
Melissa L. Rosado de Christenson, MD, FACR and Tomás 142 Bicuspid Aortic Valve
Franquet, MD, PhD Santiago Martínez-Jiménez, MD and Carlos S. Restrepo,
74 Paratracheal Air Cyst MD
Allen Heeger, DO 146 Pulmonic Stenosis
76 Bronchial Atresia Brett W. Carter, MD, CPPS
Tyler H. Ternes, MD 150 Heterotaxy
Tyler H. Ternes, MD
LUNG 154 Absence of the Pericardium
Brett W. Carter, MD, CPPS
80 Extralobar Sequestration
Tyler H. Ternes, MD CHEST WALL AND DIAPHRAGM
82 Intralobar Sequestration
Tyler H. Ternes, MD 156 Poland Syndrome
86 Diffuse Pulmonary Lymphangiomatosis Sherief H. Garrana, MD
Tyler H. Ternes, MD 158 Pectus Deformity
88 Apical Lung Hernia Sherief H. Garrana, MD and Tomás Franquet, MD, PhD
Sonia L. Betancourt-Cuellar, MD 160 Kyphoscoliosis
Carlos S. Restrepo, MD and Helen T. Winer-Muram, MD
PULMONARY CIRCULATION 164 Morgagni Hernia
Aletta Ann Frazier, MD
90 Proximal Interruption of the Pulmonary Artery 166 Bochdalek Hernia
Tyler H. Ternes, MD Aletta Ann Frazier, MD
94 Aberrant Left Pulmonary Artery
Carlos S. Restrepo, MD and Diane C. Strollo, MD, FACR SECTION 3: AIRWAY DISEASES
96 Pulmonary Arteriovenous Malformation
Sherief H. Garrana, MD INTRODUCTION AND OVERVIEW
98 Partial Anomalous Pulmonary Venous Return
170 Approach to Airways Disease
Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR
102 Scimitar Syndrome
Santiago Martínez-Jiménez, MD BENIGN NEOPLASMS
106 Pulmonary Varix
Carlos S. Restrepo, MD 172 Tracheobronchial Hamartoma
108 Meandering Pulmonary Vein Sherief H. Garrana, MD and Christopher M. Walker, MD
Melissa L. Rosado de Christenson, MD, FACR 174 Tracheobronchial Papillomatosis
Brett W. Carter, MD, CPPS

xv
 TABLE OF CONTENTS
248 Infectious Bronchiolitis
MALIGNANT NEOPLASMS John P. Lichtenberger, III, MD and Laura E. Heyneman, MD
178 Squamous Cell Carcinoma, Airways 252 Constrictive Bronchiolitis
Sonia L. Betancourt-Cuellar, MD Brett W. Carter, MD, CPPS
182 Adenoid Cystic Carcinoma 256 Swyer-James-MacLeod Syndrome
Sonia L. Betancourt-Cuellar, MD Allen Heeger, DO
186 Mucoepidermoid Carcinoma 260 Asthma
Sonia L. Betancourt-Cuellar, MD Carlos S. Restrepo, MD and Santiago Martínez-Jiménez,
190 Metastasis, Airways MD
Sonia L. Betancourt-Cuellar, MD
SECTION 4: INFECTIONS
AIRWAY NARROWING AND WALL
THICKENING INTRODUCTION AND OVERVIEW
192 Saber-Sheath Trachea 266 Approach to Infections
Brett W. Carter, MD, CPPS Santiago Martínez-Jiménez, MD
194 Tracheal Stenosis
Aletta Ann Frazier, MD GENERAL
196 Tracheobronchomalacia 268 Bronchopneumonia
Aletta Ann Frazier, MD Sherief H. Garrana, MD
200 Middle Lobe Syndrome 270 Community-Acquired Pneumonia
Santiago Martínez-Jiménez, MD Claudio Silva, MD, MSc, MBA and Jeffrey P. Kanne, MD
206 Airway Granulomatosis With Polyangiitis 274 Hospital-Acquired Pneumonia
Jorge Alberto Carrillo-Bayona, MD Jorge Alberto Carrillo-Bayona, MD
208 Tracheobronchial Amyloidosis 276 Lung Abscess
John P. Lichtenberger, III, MD and Jeffrey P. Kanne, MD Carlos S. Restrepo, MD and Helen T. Winer-Muram, MD
210 Tracheobronchopathia Osteochondroplastica 280 Septic Emboli
Sonia L. Betancourt-Cuellar, MD John P. Lichtenberger, III, MD and Carol C. Wu, MD
212 Relapsing Polychondritis
Jorge Alberto Carrillo-Bayona, MD BACTERIA
214 Rhinoscleroma 284 Pneumococcal Pneumonia
Jorge Alberto Carrillo-Bayona, MD Jorge Alberto Carrillo-Bayona, MD
288 Staphylococcal Pneumonia
BRONCHIAL DILATATION AND IMPACTION
Jorge Alberto Carrillo-Bayona, MD
216 Bronchitis 292 Klebsiella Pneumonia
Carlos S. Restrepo, MD and Carol C. Wu, MD Jorge Alberto Carrillo-Bayona, MD
218 Bronchiectasis 294 Pseudomonas Pneumonia
Sherief H. Garrana, MD and Laura E. Heyneman, MD Sherief H. Garrana, MD
222 Cystic Fibrosis 296 Legionella Pneumonia
Aletta Ann Frazier, MD Carlos S. Restrepo, MD and Jeffrey P. Kanne, MD
226 Allergic Bronchopulmonary Aspergillosis 298 Nocardiosis
Allen Heeger, DO Carlos S. Restrepo, MD and Helen T. Winer-Muram, MD
230 Primary Ciliary Dyskinesia 300 Actinomycosis
Melissa L. Rosado de Christenson, MD, FACR and Carlos S. Carlos S. Restrepo, MD and Tomás Franquet, MD, PhD
Restrepo, MD 302 Melioidosis
234 Mounier-Kuhn Syndrome Jorge Alberto Carrillo-Bayona, MD
Sonia L. Betancourt-Cuellar, MD and Carlos S. Restrepo, 304 Tuberculosis
MD Melissa L. Rosado de Christenson, MD, FACR
236 Williams-Campbell Syndrome 308 Nontuberculous Mycobacterial Infection
Sonia L. Betancourt-Cuellar, MD Kyung Soo Lee, MD
238 Broncholithiasis 312 Mycoplasma Pneumonia
Santiago Martínez-Jiménez, MD Jorge Alberto Carrillo-Bayona, MD

EMPHYSEMA AND SMALL AIRWAY DISEASES VIRUSES

240 Centrilobular Emphysema 314 Viral Pneumonia
Allen Heeger, DO Tomás Franquet, MD, PhD
244 Paraseptal Emphysema 318 Influenza Pneumonia
Allen Heeger, DO Carlos S. Restrepo, MD and Helen T. Winer-Muram, MD
246 Panlobular Emphysema
Allen Heeger, DO

xvi
 TABLE OF CONTENTS
320 Cytomegalovirus Pneumonia
Carol C. Wu, MD and Carlos S. Restrepo, MD
UNCOMMON NEOPLASMS
324 COVID-19 398 Pulmonary Hamartoma
Santiago Martínez-Jiménez, MD and Sherief H. Garrana, Allen Heeger, DO
MD 402 Bronchial Carcinoid
Sonia L. Betancourt-Cuellar, MD
FUNGI 406 Neuroendocrine Carcinoma
328 Histoplasmosis Cristina Fuss, MD and Sonia L. Betancourt-Cuellar, MD
Carlos S. Restrepo, MD and Helen T. Winer-Muram, MD 410 Kaposi Sarcoma
332 Coccidioidomycosis Carlos S. Restrepo, MD and Brett W. Carter, MD, CPPS
Carlos S. Restrepo, MD and Diane C. Strollo, MD, FACR
334 Blastomycosis
LYMPHOMA AND LYMPHOPROLIFERATIVE
Carlos S. Restrepo, MD and Diane C. Strollo, MD, FACR
DISORDERS
336 Cryptococcosis 414 Follicular Bronchiolitis
Brett W. Carter, MD, CPPS Jorge Alberto Carrillo-Bayona, MD
338 Paracoccidioidomycosis 418 Lymphoid Interstitial Pneumonia
Jorge Alberto Carrillo-Bayona, MD Jorge Alberto Carrillo-Bayona, MD
340 Aspergillosis 422 Nodular Lymphoid Hyperplasia
Allen Heeger, DO Santiago Martínez-Jiménez, MD
346 Zygomycosis 424 Post-Transplant Lymphoproliferative Disease
Sonia L. Betancourt-Cuellar, MD John P. Lichtenberger, III, MD and Christopher M. Walker,
348 Pneumocystis jirovecii Pneumonia MD
Sherief H. Garrana, MD 428 Pulmonary Lymphoma
Sonia L. Betancourt-Cuellar, MD
PARASITES
352 Dirofilariasis
METASTATIC DISEASE
Carlos S. Restrepo, MD and Tomás Franquet, MD, PhD 432 Hematogenous Metastases
354 Hydatidosis Aletta Ann Frazier, MD
Carlos S. Restrepo, MD and Tomás Franquet, MD, PhD 436 Lymphangitic Carcinomatosis
356 Strongyloidiasis Sonia L. Betancourt-Cuellar, MD
Carlos S. Restrepo, MD and Brett W. Carter, MD, CPPS 440 Tumor Emboli
358 Amebiasis Carlos S. Restrepo, MD and Florian J. Fintelmann, MD,
Carlos S. Restrepo, MD FRCPC
362 Schistosomiasis
Carlos S. Restrepo, MD SECTION 6: INTERSTITIAL, DIFFUSE, AND
INHALATIONAL LUNG DISEASE
SECTION 5: PULMONARY NEOPLASMS
INTRODUCTION AND OVERVIEW
INTRODUCTION AND OVERVIEW 446 Approach to Interstitial, Diffuse, and Inhalational
366 Approach to Pulmonary Neoplasms Lung Disease
Melissa L. Rosado de Christenson, MD, FACR Santiago Martínez-Jiménez, MD

LUNG CANCER IDIOPATHIC INTERSTITIAL LUNG DISEASES

372 Solitary Pulmonary Nodule 448 Acute Respiratory Distress Syndrome (ARDS)
Melissa L. Rosado de Christenson, MD, FACR Julia Alegría, MD
378 Adenocarcinoma 450 Acute Interstitial Pneumonia
Tyler H. Ternes, MD and Santiago Martínez-Jiménez, MD Carlos S. Restrepo, MD
384 Squamous Cell Carcinoma 454 Idiopathic Pulmonary Fibrosis
Sonia L. Betancourt-Cuellar, MD Julia Alegría, MD
388 Small Cell Carcinoma 458 Nonspecific Interstitial Pneumonia
Sonia L. Betancourt-Cuellar, MD Tyler H. Ternes, MD
392 Multifocal Lung Cancer 462 Organizing Pneumonia
Tyler H. Ternes, MD Jorge Alberto Carrillo-Bayona, MD
394 Lung Cancer Screening 466 Sarcoidosis
Sonia L. Betancourt-Cuellar, MD Sonia L. Betancourt-Cuellar, MD
472 Pleuropulmonary Fibroelastosis
Santiago Martínez-Jiménez, MD

xvii
 TABLE OF CONTENTS
548 Dendriform Pulmonary Ossification
SMOKING-RELATED DISEASES Jorge Alberto Carrillo-Bayona, MD
474 Respiratory Bronchiolitis and RBILD
Jorge Alberto Carrillo-Bayona, MD SECTION 7: CONNECTIVE TISSUE
476 Desquamative Interstitial Pneumonia DISORDERS, IMMUNOLOGICAL
Jorge Alberto Carrillo-Bayona, MD DISEASES, AND VASCULITIS
480 Pulmonary Langerhans Cell Histiocytosis
Tyler H. Ternes, MD INTRODUCTION AND OVERVIEW
484 Combined Pulmonary Fibrosis and Emphysema 552 Approach to Connective Tissue Disorders,
Aletta Ann Frazier, MD Immunological Diseases, and Vasculitis
Santiago Martínez-Jiménez, MD
PNEUMOCONIOSIS
486 Asbestosis IMMUNOLOGICAL AND CONNECTIVE TISSUE
Carlos S. Restrepo, MD and Helen T. Winer-Muram, MD DISORDERS
490 Silicosis and Coal Worker's Pneumoconiosis 554 Interstitial Pneumonia With Autoimmune Features
Brett W. Carter, MD, CPPS and Julia Alegría, MD (IPAF)
494 Hard Metal Pneumoconiosis Santiago Martínez-Jiménez, MD
Carlos S. Restrepo, MD 558 Rheumatoid Arthritis
496 Berylliosis Sonia L. Betancourt-Cuellar, MD
Sonia L. Betancourt-Cuellar, MD 562 Scleroderma
500 Silo-Filler's Disease Julia Alegría, MD and Jonathan Hero Chung, MD
Tyler H. Ternes, MD 566 Mixed Connective Tissue Disease
Julia Alegría, MD and Laura E. Heyneman, MD
OTHER INHALATIONAL DISORDERS 568 Polymyositis/Dermatomyositis
502 Hypersensitivity Pneumonitis Julia Alegría, MD and Carlos S. Restrepo, MD
Julia Alegría, MD 572 Systemic Lupus Erythematosus
506 Smoke Inhalation Julia Alegría, MD and Laura E. Heyneman, MD
John P. Lichtenberger, III, MD and Terrance Healey, MD 576 Sjögren Syndrome
510 E-Cigarette or Vaping Product Use-Associated Lung Sonia L. Betancourt-Cuellar, MD
Injury (EVALI) 582 Ankylosing Spondylitis
Carlos S. Restrepo, MD Tyler H. Ternes, MD
512 Aspiration 586 Inflammatory Bowel Disease
Carlos S. Restrepo, MD Sonia L. Betancourt-Cuellar, MD
516 Excipient Lung Disease 590 Erdheim-Chester Disease
Santiago Martínez-Jiménez, MD Carlos S. Restrepo, MD

EOSINOPHILIC LUNG DISEASE THORACIC COMPLICATIONS IN

520 Acute Eosinophilic Pneumonia IMMUNOCOMPROMISED PATIENTS
Jorge Alberto Carrillo-Bayona, MD 592 Hematopoietic Stem Cell Transplantation
522 Chronic Eosinophilic Pneumonia Sonia L. Betancourt-Cuellar, MD
Jorge Alberto Carrillo-Bayona, MD 596 Solid Organ Transplantation
524 Hypereosinophilic Syndrome Sonia L. Betancourt-Cuellar, MD
Jorge Alberto Carrillo-Bayona, MD 600 HIV/AIDS
Sonia L. Betancourt-Cuellar, MD
METABOLIC DISEASES AND MISCELLANEOUS 604 Neutropenia
CONDITIONS Sonia L. Betancourt-Cuellar, MD
526 Alveolar Microlithiasis
Jorge Alberto Carrillo-Bayona, MD PULMONARY HEMORRHAGE AND
528 Metastatic Pulmonary Calcification VASCULITIS
Tyler H. Ternes, MD 608 Idiopathic Pulmonary Hemosiderosis
532 Lymphangioleiomyomatosis Allen Heeger, DO
Melissa L. Rosado de Christenson, MD, FACR 610 Goodpasture Syndrome
536 Pulmonary Amyloidosis Aletta Ann Frazier, MD
Laura E. Heyneman, MD 614 Pulmonary Granulomatosis With Polyangiitis
540 Pulmonary Alveolar Proteinosis Aletta Ann Frazier, MD
Julia Alegría, MD and Jorge Alberto Carrillo-Bayona, MD 618 Eosinophilic Granulomatosis With Polyangiitis
544 Lipoid Pneumonia Carlos S. Restrepo, MD and Jonathan Hero Chung, MD
Sonia L. Betancourt-Cuellar, MD

xviii
 TABLE OF CONTENTS
620 Behçet Syndrome 688 Coronary Artery Aneurysm
Aletta Ann Frazier, MD Julia Alegría, MD and John P. Lichtenberger, III, MD
622 Necrotizing Sarcoid Granulomatosis 690 Paraesophageal Varices
Aletta Ann Frazier, MD John P. Lichtenberger, III, MD
692 Mediastinal Lymphangioma
SECTION 8: MEDIASTINAL Aletta Ann Frazier, MD
ABNORMALITIES 694 Mediastinal Hemangioma
Aletta Ann Frazier, MD
INTRODUCTION AND OVERVIEW
626 Approach to Mediastinal Abnormalities GLANDULAR ENLARGEMENT
Melissa L. Rosado de Christenson, MD, FACR 696 Thymic Hyperplasia
Santiago Martínez-Jiménez, MD
PRIMARY NEOPLASMS 700 Mediastinal Goiter
630 Thymoma Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR
634 Thymic Neuroendocrine Neoplasm DISEASES OF THE ESOPHAGUS
Sherief H. Garrana, MD 704 Achalasia
636 Thymic Carcinoma Julia Alegría, MD
Sherief H. Garrana, MD 706 Esophageal Diverticula
638 Thymolipoma Julia Alegría, MD and Tomás Franquet, MD, PhD
Melissa L. Rosado de Christenson, MD, FACR 708 Esophageal Stricture
640 Mediastinal Teratoma Claudio Silva, MD, MSc, MBA and Santiago Martínez-
John P. Lichtenberger, III, MD Jiménez, MD
644 Mediastinal Seminoma 710 Esophageal Carcinoma
Aletta Ann Frazier, MD Sonia L. Betancourt-Cuellar, MD
646 Nonseminomatous Malignant Germ Cell Neoplasm
Aletta Ann Frazier, MD MISCELLANEOUS CONDITIONS
648 Neurogenic Neoplasms of the Nerve Sheath 714 Mediastinal Lipomatosis
Sherief H. Garrana, MD Claudio Silva, MD, MSc, MBA
652 Neurogenic Neoplasms of the Sympathetic Ganglia 716 Mediastinitis
John P. Lichtenberger, III, MD Claudio Silva, MD, MSc, MBA
654 Neurofibromatosis 720 Mediastinal Fat Necrosis
Sonia L. Betancourt-Cuellar, MD Allen Heeger, DO
724 Extramedullary Hematopoiesis
LYMPHADENOPATHY
Claudio Silva, MD, MSc, MBA and Santiago Martínez-
656 Metastatic Disease, Lymphadenopathy Jiménez, MD
Brett W. Carter, MD, CPPS 726 Hiatal Hernia
660 Mediastinal Lymphoma Tyler H. Ternes, MD
Sherief H. Garrana, MD
664 Fibrosing Mediastinitis SECTION 9: CARDIOVASCULAR
Sherief H. Garrana, MD DISORDERS
668 Castleman Disease
Brett W. Carter, MD, CPPS INTRODUCTION AND OVERVIEW
732 Approach to Cardiovascular Disorders
CYSTS Santiago Martínez-Jiménez, MD
672 Bronchogenic Cyst
Aletta Ann Frazier, MD DISEASES OF THE AORTA AND GREAT
676 Esophageal Duplication Cyst VESSELS
Aletta Ann Frazier, MD 736 Atherosclerosis
678 Pericardial Cyst Carlos S. Restrepo, MD and Santiago Martínez-Jiménez,
Aletta Ann Frazier, MD MD
682 Thymic Cyst 740 Aortic Aneurysm
Aletta Ann Frazier, MD Carlos S. Restrepo, MD and Santiago Martínez-Jiménez,
MD
VASCULAR LESIONS
742 Acute Aortic Syndromes
684 Mediastinal Vascular Masses Santiago Martínez-Jiménez, MD and Julia Alegría, MD
Brett W. Carter, MD, CPPS

xix
Another random document with
no related content on Scribd:
 We now come to Ebn Batúta; and we again find the same
surprising harmony between the fact regarding Bórnu, as mentioned
by him, and the dates of the chronicle. The famous and enterprising
traveller of Tangiers, on his return-journey from his visit to Western
Sudán, left the capital of Mélle or Máli (that is, Mungo Park’s Jára)
the 22nd of Moharrem, 754, and, proceeding by way of Timbúktu or
Túmbutu, and thence down the Ísa or Niger to Gágho or Gógo, and
thence to Tekádda,[44] in speaking about the copper found in the
mines near this town, relates that the bars made of it were exported
to Góber and Rágha (or rather Ragháy), and also to Bórnu, and then
adds the interesting fact that the name of the ruling king of the latter
country was Edrís.
Now if we follow implicitly the dates of the chronicle, Edrís ben
Ibrahím (Nikále) ascended the throne in that very year (753) when,
according to this precious and unimpeachable testimony of the
illustrious and intelligent traveller, he actually occupied the throne.
The very remarkable and really surprising harmony here shown to
exist between the chronicle and the dates which have come to our
knowledge from other sources, will, I hope, give to any unprejudiced
mind some degree of confidence in the authenticity of that
document, and will make him aware of its superiority over the
information of a man like Leo Africanus, or rather Hasen Ebn
Mohammed el Wasas, who, though he undoubtedly has, and will
always have, the merit of having given to Europe a clear general
view of the political and linguistic groups of Central Africa, yet, on
account of the manner in which his report was drawn up (merely
from memory, after the lapse of many years), cannot be a decisive
authority on any special circumstance. Hence, when he states that
the name of the king of Bórnu, at the time when he visited the
country, was Abraham (Ibrahím), we may confidently assume that he
is wrong, and that he speaks of the illustrious conqueror ʿAlí ben
Dúnama, who restored peace and glory to that distracted country,
and, on account of his warlike character and his various expeditions,
obtained the surname el Gházi. I shall return to this subject in the
chronological table, in speaking of the reign of ʿAlí ben Dúnama.
 As for the document mentioned above as No. 5, it contains a few
valuable dates with regard to those Bórnu kings who reigned near
the time when the author obtained his information in Tripoli, while for
the older times, about which the people could only inform him “par
tradition des leurs pères,” his information is of little value. The most
important dates which it contains are those which have reference to
the time of the accession to the throne of the three Bórnu kings,
ʿAbdallah ben Dúnama, Háj ʿOmár, and Háj ʿAlí; and these vary but
little from the dates computed from the chronicle, and serve
therefore to confirm its accuracy.
However, it is not my design to vindicate this chronicle from all
possibility of error; but my object is to show that its general
character, dry and meagre as it is, has the strongest claim to
authenticity. Indeed I am sure that it can be fully relied upon, all
uncertainty being reduced to a space of one or two years; I may
therefore be allowed to assert that the chronological table, which I
shall give in the Appendix, is something more than a mere fairy tale.
But in this place, I think it well to offer a few general remarks on the
characteristic features of the history of Bórnu.
I have first to speak of the origin of the Séfuwa or Dúguwa. We
have already seen that the chronology of the Bórnu people, if
palpable absurdities be left out of consideration, does not carry their
history further down than the latter half of the ninth century of our
era. Accordingly there can be no further question as to whether Séf
was really the son of the celebrated Dhu Yazan, and identical with
Séf Dhu Yazan, the last native ruler of the Himyaritic kingdom, who
celebrated his accession to the throne in the famous castle of
Gumdán, and with the assistance of Khosru Parvis liberated Yeman
from the dominion of the Abyssinians. I frankly confess that, while
Ibrahím the son of Séf, as “father of the king” (as he appears to have
been entitled occasionally), seems to me to have a really historical
character, I entertain sincere doubts whether Séf be not a mere
imaginary personage, introduced into the pedigree expressly in order
to connect it with Yeman. Indeed, in one short list of Bórnu kings
which I possess, several princes are mentioned before Séf, whose
names, such as Futírmi, Hálar Sukayámi, Halármi, Bunúmi, Rizálmi,
Mairími, have quite a Kanúri character. As the reader will see, I do
not at all doubt of some connection existing between the ruling family
of Bórnu and the Himyaritic or Kushitic stock; but I doubt its
immediate descent from the royal Himyaritic family.
But be this as it may, I think that Leo Africanus, who is a very good
authority for general relations, is right in stating that the kings of
Bórnu originated from the Libyan tribe of the Bardoa, a tribe also
mentioned by Makrízí as Berdʿoa. That there is an ethnological
connection between the names Bérnu or Bórnu, Bórgu, Berdʿoa,
Berdáma, Berauni, Berber, can scarcely be doubted; but to many the
Berdʿoa might seem to have nearer relation with the Tedá or Tébu
than with the real Berber or Mazígh. Sultan Béllo certainly, in the
introduction to his history of the conquests of the Fúlbe, expressly
says that the Bórnu dynasty was of Berber origin; and it is on this
account that the Háusa people call every Bórnu man “ba-Bérberche,”
and the Bórnu nation “Bérbere.” This view of the subject is confirmed
by the distinct statement of Makrízí, who says that that was the
common tradition of the people at his time—“it is said that they are
descended from the Berbers,”—and moreover in another passage
informs us that the king of Kánem was a nomade, or wanderer;
although it seems that this statement refers properly to the Bulála
dynasty.
Before the time of Sélma, or Sélmama, the son of Bíkoru, whose
reign began about a.h. 581, the kings are stated by the chronicle to
have been of a red complexion, like the Arabs; and to such an origin
from the red race, the Syrian-Berber stock, is certainly to be referred
their custom of covering the face and never showing the mouth, to
which custom Ebn Batúta adverts in speaking of King Edrís, who
ruled in his time. To this origin is also to be referred the custom, till
recently practised, of putting the new king upon a shield, and raising
him up over the heads of the people, as well as the polity of the
empire, which originally was entirely aristocratical, based upon a
council of twelve chiefs, without whose assent nothing of importance
could be undertaken by the king.
We have a very curious statement concerning the Bórnu empire,
emanating from Lucas, the traveller employed by the African
Association, and based on the authority of his Arab informants,
principally Ben ʿAlí, who no doubt was a very clever and intelligent
man. He describes the Bórnu kingdom as an elective monarchy, the
privilege of choosing a successor among the sons of a deceased
king, without regard to priority of birth, being conferred by the nation
on three of the most distinguished men of the country. He does not
say whether these belonged to the courtiers, or whether every
private individual might be called upon promiscuously to fulfil this
important duty; but the strict etiquette of the court of Bórnu makes it
probable that the former was the case. Be this as it may, the choice
being made, the three electors proceeded to the apartment of the
sovereign elect, and conducted him in silence to the gloomy place in
which the unburied corpse of his deceased father was deposited; for
till this whole ceremony was gone through the deceased could not
be interred. There, over the corpse of his deceased father, the newly
elected king seems to have entered into some sort of compromise
sanctioned by oath, binding himself that he would respect the
ancient institutions, and employ himself for the glory of the country.
I shall have to mention a similar custom still prevailing at the
present day in the province of Múniyó, which belonged to that part of
the empire called Yerí, while the dynasty of the Múniyóma probably
descended from the Berber race. Every newly elected Múniyóma,
still at the present day, is in duty bound to remain for seven days in a
cave hollowed out by nature, or by the hand of man, in the rock
behind the place of sepulchre of the former Múniyóma, in the ancient
town of Gámmasak, although it is quite deserted at present, and
does not contain a living soul.
But that not only the royal family, but even a great part of the
whole nation, or rather one of the nations which were incorporated
into the Bórnu empire, was of Berber origin, is still clear so late as
the time of Edrís Alawóma, that is to say, only two centuries and a
half ago; for in the report of his expeditions, constant mention is
made of the Berber tribes (“kabáíl el Beráber”) as a large component
part of his army, and constantly two parts of this army are
distinguished as the Reds, “el Áhhmar,” and the Blacks, “eʾ Súd.”
This part of the population of Bórnu has separated from the rest, I
suspect in consequence of the policy of ʿAlí, the son and successor
of Háj ʿOmár, a very warlike prince, who, in the second half of the
seventeenth century, waged a long war with Ágades.
Viewed in the light thus shed by past history, the continual and
uninterrupted warlike expeditions made by the Tuarek at the present
time against the northern regions of Bórnu and against Kánem
assume quite a new and far more interesting character. Now if it be
objected that the Kanúri or Bórnu language does not appear to
contain any Berber elements (which indeed it does not), I have only
to adduce the exactly parallel example of the Bulála, a brother
dynasty of the Bórnu royal family, descended from the same stock,
who, having settled and founded a dynasty among the tribe of the
Kúka, in the territory of Fíttri, still continue to speak their native
language, that is the Kanúri, in the time of Leo,[45] but have now
entirely forgotten it, adopting the language of the people over whom
they ruled; and similar examples are numerous.
A second point which deserves notice is, that the Kanúri even at
the present day call people in general, but principally their kings,
always after the name of their mother, and that the name of the
mother’s tribe is almost continually added in the chronicle as a
circumstance of the greatest importance. Thus the famous king
Dúnama ben Selmʿaa is known in Bórnu generally only under the
name of Díbalámi, from the name of his mother Díbala; and the full
form of his royal title is Díbalámi Dúnama Selmámi, his mother’s
name, as the most noble and important, preceding his individual
name, which is followed by the name derived from his father. It is
also evident, even from the dry and jejune report of the chronicle,
what powerful influence the Walíde or “Mágira”—this is her native
title—exercised in the affairs of the kingdom; I need only mention the
examples of Gúmsu (“gúmsu” means the chief wife) Fasámi, who
imprisoned her son Bíri, when already king, for a whole year, and of
Áʿaishad or ʿAisa, the mother of Edrís, who for a number of years
exercised such paramount authority, that in some lists, and even by
many ʿulama at the present time, her name is inserted in the list of
the sovereigns of the country.
 These circumstances may be best explained by supposing that a
kind of compromise took place between the strangers—Berbers, or
rather Imóshagh (Mazígh) from the tribe of the Berdʿoa—and the
tribe or tribes among whom they settled, just in the same manner as
we have seen that a stipulation of the same kind was probably made
between the conquering Kél-owí and the ancient inhabitants of Aír of
the Góber race; and the same circumstances, with similar results,
are observable in ancient times, in the relations subsisting between
the Grecian colonists and the original inhabitants of Lycia.
The most important among the indigenous tribes of Kánem are the
Kíye or Beni Kíya, also mentioned in the time of Edrís Alawóma, the
Meghármah, who may possibly be identical with the Ghemármah,
the Temághera (evidently a Berber name), the Débiri, the Kúnkuna,
at present established in Kárgá, and finally the Tébu or Tubu, or
rather Tedá. Of all these the last-named constituted by far the most
important and most numerous tribe. To them belonged the mother of
Dúnama ben Humé, the most powerful of the older kings of Bórnu,
who appears to have thrice performed the pilgrimage to Mekka.
Indeed it would seem that the real talisman which Díbalámi Dúnama
Selmámi spoiled consisted in the friendly relation between the
Berauni or Kanúri and the Tébu, which was so intimate that the
name of Berauni, which originally belonged to the inhabitants of
Bórnu, is still at present the common name given by the Tuarek to
the Tébu; or rather, the latter are a race intimately related to the
original stock of the Kanúri, as must become evident to every
unprejudiced mind that investigates their language.
How powerful a tribe the Tedá were, is sufficiently shown by the
length of the war which they carried on with that very king Dúnama
Selmámi, and which is said to have lasted more than seven years.
Indeed, it would seem as if it had been only by the assistance of this
powerful tribe that the successors of Jíl Shikomémi were able to
found the powerful dynasty of the Bulála, and to lay the foundation of
the great empire called by Leo Gaoga, comprehending all the
eastern and north-eastern parts of the old empire of Kánem, and
extending at times as far as Dóngola, so that in the beginning of the
sixteenth century it was larger than Bórnu. Even in the latter half of
the sixteenth century, the Tedá appears to have constituted a large
proportion of the military force of the Bulála in Kánem; and great
numbers of them are said, by the historian of the powerful king Edrís
Alawóma, to have emigrated from Kánem into Bórnu, in
consequence of the victories obtained by that prince over the Bulála.
At that time they seem to have settled principally in the territories of
the Koyám, a tribe very often mentioned in the book of Imám Ahmed
as forming part of the Bórnu army, and with whom at present they
are completely intermixed. It is very remarkable, that neither by the
chronicle, nor by the historian of Edrís Alawóma, the large tribe of
the Mánga, which evidently formed a very considerable element in
the formation of the Bórnu nation, is ever once mentioned.
While the tribes above enumerated were more or less absorbed by
the empire of Kánem, and, in the course of time, adopted the
Mohammedan religion professed by its rulers, there was on the other
hand a very numerous indigenous tribe which did not become
amalgamated with the conquering element, but, on the contrary,
continued to repel it in a hostile manner, and for a long time
threatened its very existence. These were the “Soy” or “Só,” a tribe
settled originally in the vast territory enclosed towards the north and
north-west by the komádugu Wáube, erroneously called the Yeou,
and towards the east by the Shári, and divided, as it would seem,
into several small kingdoms.
This powerful tribe was not completely subjugated before the time
of Edrís Alawóma, or the latter part of the sixteenth century; and it
might be matter of surprise that they are not mentioned at all by the
chronicle before the middle of the fourteenth century, if it were not
that even circumstances and facts of the very greatest importance
are passed over in silence by this arid piece of nomenclature. It
would therefore be very inconsistent to conclude from this silence,
that before the period mentioned the princes of Kánem had never
come into contact with the tribe of the Soy; the reason why the
chronicle, sparing as it is of information, could not any longer pass
them over in silence, was that in the space of three years they had
vanquished and killed four successive kings. The places mentioned
in the list, where the first three of these princes were slain, cannot be
identified with absolute certainty; but as for Nánighám, where
Mohammed ben ʿAbdallah was killed, it certainly lay close to, and
probably in, the territory of the Soy. After this period we learn
nothing, with regard to this tribe until the time of Edrís Alawóma,
although it seems probable that Edrís Nikálemi, the successor of
Mohammed ben ʿAbdallah, and the contemporary of Ebn Batúta,
had first to gain a victory over the Soy, before he was able to sit
down quietly upon his throne.
Altogether, in the history of Bórnu we can distinguish the following
epochs. First, the rise of power in Kánem, Njímiye being the capital
of the empire, silent and imperceptible till we see on a sudden, in the
beginning of the twelfth century, the powerful prince Dúnama ben
Humé start forth under the impulse of Islám, wielding the strength of
a young and vigorous empire, and extending his influence as far as
Egypt. The acme, or highest degree of prosperity, of this period
coincides with the reign of Díbalámi Dúnama Selmámi, in the middle
of the thirteenth century, during the prime of the dynasty of the Beni
Háfis in Tunis. But this reign already engendered the germs of
decay; for during it the two cognate elements of which the empire
consisted, namely the Tedá and the Kanúri, were disunited, and it
yielded too much influence to the aristocratical element, which was
represented by the twelve great offices, an institution which seems to
deserve particular attention.
The consequence was, that a series of civil wars and regicides
ensued, interrupted only by the more tranquil reign of Ibrahím
Nikálemi in the first half of the fourteenth century, which was
followed, however, by the most unfortunate period of the empire,
when the great native tribe of the Soy burst forth and killed four kings
in succession. Then followed another respite from turmoil, just at the
time when Ebn Batúta visited Negroland; but the son of the very king
who in the time of that distinguished traveller ruled over Bórnu fell
the first victim in the struggle that ensued with a power which had
arisen from the same root, had gained strength during the civil wars
of Bórnu, and which now threatened to swallow it up altogether. This
was the dynasty of the Bulála, which, originating with the fugitive
Bórnu prince Jíl Shikomémi, had established itself in the district of
Fíttri over the tribe of the Kúka, and from thence spread its dominion
in every direction till, after a sanguinary struggle, it conquered
Kánem, and forced the Kanúri dynasty to seek refuge in the western
provinces of its empire, about the year 1400 of our era.
The Bórnu empire (if we may give the name of empire to the
shattered host of a belligerent tribe driven from their home and
reduced to a few military encampments) for the next seventy years
seemed likely to go to pieces altogether, till the great king ʿAli
Dúnamámi opened another glorious period; for having at length
mastered the aristocratical element, which had almost overwhelmed
the monarchy, he founded as a central point of government a new
capital or “bírni,” Ghasréggomo, the empire having been without a
fixed centre since the abandonment of Njímiye. It was in his time that
Leo Africanus visited Negroland, where he found the Bulála empire
(Gaoga) still in the ascendant: but this was changed in the beginning
of the sixteenth century, even before the publication of his account;
for in the hundred and twenty-second (lunar) year from the time
when ʿOmár was compelled to abandon his royal seat in Njímiye,
ceding the rich country of Kánem, the very nucleus of the empire, to
his rivals, the energetic king Edrís Katakarmábi entered that capital
again with his victorious army, and from that time down to the
beginning of the present century Kánem has remained a province of
Bórnu, although it was not again made the seat of government.
Altogether the sixteenth century is one of the most glorious
periods of the Bórnu empire, adorned as it is by such able princes as
the two Edrís and Mohammed, while in Western Negroland the great
Sónghay empire went to pieces, and was finally subjugated by Mulay
Hámed el Mansúr, the Emperor of Morocco. Then followed a quieter
period, and old age seemed gradually to gain on the kingdom, while
pious and peaceful kings occupied the throne, till in the middle of the
last century the energetic and enterprising king ʿAli ʿOmármi began a
violent struggle against that very nation from which the Bórnu
dynasty had sprung, but which had now become its most fearful
enemy—the Imóshagh or Tuarek. He made great exertions in every
direction; but his efforts seem to have resembled the convulsions of
death, and being succeeded by an indolent king, for such was
Ahmed, the fatal hour, which was to accomplish the extinction of the
dynasty of the Séfuwa, rapidly approached. At last, when the very
centre of the empire had already fallen a prey to a new nation which
had started forth on a career of glory, the Fúlbe or Felláta, there
arose a stranger, a nationalized Arab, who, in saving the last
remains of the kingdom, founded a new dynasty, that of the
Kánemíyín, which, after having shone forth very brightly under its
founder, was recently reduced by civil discord, and seems now
destined to a premature old age.
 CHAPTER XXX.
THE CAPITAL OF BÓRNU.

I shall now give an account of my stay in Kúkawa before setting

out on my journey to Ádamáwa. Regarding Kúkawa only as the basis
of my further proceedings, and as a necessary station already
sufficiently known to the European public by the long stay of the
former expedition, I endeavoured to collect as much information as
possible with regard to the surrounding countries. Two of my friends
were distinguished by a good deal of Mohammedan learning, by the
precision with which they recollected the countries they had
wandered through, and by dignified manners; but they differed much
in character, and were inclined to quarrel with each other as often as
they happened to meet in my house.
These two men, to whom I am indebted for a great deal of
interesting and precise information, were the Arab Ahmed bel Mejúb,
of that division of the tribe of the Welád bu-Sebʿa who generally live
in the Wady Sákiyet el Hamra, to the south of Morocco, and the Púllo
Ibrahím son of the Sheikh el Mukhtár, in Kaháide on the Senegal,
and cousin of the late Mohammed el Amín, the energetic prince of
Fúta-Tóro. Ahmed had travelled over almost the whole of Western
Africa, from Arguín on the ocean as far as Bagírmi, and had spent
several years in Ádamáwa, of which country he first gave me an
exact description, especially with regard to the direction of the rivers.
He was a shrewd and very intelligent man; yet he was one of those
Arabs who go round all the courts of the princes of Negroland, to
whatever creed or tribe they may belong, and endeavour to obtain
from them all they can by begging and by the parade of learning. I
esteemed him on account of his erudition, but not in other respects.
Quite a different person was the Púllo Ibrahím—a very proud
young man, fully aware of the ascendency, and strongly marked with
the distinguishing character, of the nation to which he belonged. He
had performed the pilgrimage to Mekka, crossing the whole breadth
of Africa from west to east, from warm religious feeling mixed up with
a little ambition, as he knew that such an exploit would raise him
highly in the esteem of his countrymen, and secure to him a high
position in life. He had been two years a hostage in Ndér (St. Louis),
and knew something about the Europeans. It had struck him that the
French were not so eager in distributing bibles as the English, while
he had truly remarked that the former were very sensible of the
charms of the softer sex, and very frequently married the pretty
daughters of the Dembaséga. He obtained from me, first the Zabúr,
or the Psalms of David, which even the Arabs esteem very highly,
and would esteem much more if they were translated into a better
sort of Arabic, and afterwards the whole Bible, which he wished to
take with him on his long land journey.
The Arabs and the Fúlbe, as is well known, are in almost continual
warfare all along the line from the Senegal as far as Timbúktu; and it
was most interesting for me to see him and Ahmed in violent
altercation about the advantages of their respective nations, while I
was thereby afforded an excellent means of appreciating their
reports with regard to the state of the tribes and countries along the
Senegal. The way in which they began to communicate to me their
information was in itself expressive of their respective characters,
Ahmed protesting that, before he dared to communicate with me, he
was compelled to ask the permission of the vizier, while Ibrahím
laughed at him, declaring that he felt himself fully authorized to give
me any information about Negroland. Ibrahím became an intimate
friend of mine, and took a lively interest in me, particularly
commiserating my lonely situation in a foreign country, far from
home, without the consolations of female companionship.
As an example of the risks which European travellers may incur by
giving medicines to natives to administer to themselves at home, I
will relate the following incident. Ibrahím told me one day that he
wanted some cooling medicine; and I gave him two strong doses of
Epsom salts, to use occasionally. He then complained the following
day that he was suffering from worms; and when I told him that the
Epsom salts would not have the effect of curing this complaint, but
that worm-powder would, he begged me to give him some of the
latter; and I gave him three doses to use on three successive days.
However, my poor friend, though an intelligent man, thought that it
might not be amiss to take all this medicine at once, viz. four ounces
of Epsom salts and six drachms of worm-powder; and the reader
may imagine the effect which this dose produced upon a rather
slender man. Unfortunately, I had just taken a ride out of the town;
and he remained for full two days in a most desperate state, while
his friends, who had sent in vain to my house to obtain my
assistance, were lamenting to all the people that the Christian had
killed their companion, the pious pilgrim.
Besides these two men, there were many interesting strangers at
that time in Kúkawa, from whom I learnt more or less. Some of them
I shall here mention, as their character and story will afford the
reader a glance at one side of life in Negroland. A man who had
performed travels of an immense extent, from Khórasán in the east
as far as Sansándi in the west, and from Tripoli and Morocco in the
north as far as Asiantí and Jenakhéra and Fertít towards the south,
would have been of great service, if he had preserved an exact
recollection of all the routes which he had followed in his devious
wanderings; but as it was, I could only gather from him some general
information, the most interesting part of which had reference to Mósi
or rather Móre, a large and populous country known by name
already, from Sultan Béllo’s curious communications to Captain
Clapperton, but always misplaced in the maps, and its capital
Wóghodoghó.
This enterprising man, who generally travelled as a dervish, had
gone from Sofára on the Máyo balléo or Niger, between Hamdalláhi
and Ségo, across a most unsettled country, to Wóghodoghó; but he
was unable to give me any precise details with regard to it, and I
never met another person who had travelled this dangerous route.
He had also travelled all along the pagan states to the south of
Bagírmi and Wadáy, and advised me strongly, if it were my plan to
penetrate to the Upper Nile (as, indeed, I then intended,
notwithstanding my total want of means), to adopt the character of a
dervish, which he deemed essential for my success. But while such
a character might, indeed, insure general success, it would preclude
the possibility of making any accurate observations, and would
render necessary the most painful, if not insupportable, privations.
And on the whole this poor fellow was less fortunate than I; for in the
year 1854 he was slain on that very route from Yóla to Kúkawa
which I myself had twice passed successfully. He was a native of
Baghdád, and called himself Sheríf Ahmed el Baghdádi.
There was another singular personage, a native of Sennár, who
had been a clerk in the Turkish army, but, as malicious tongues gave
out, had been too fond of the cash entrusted to his care, and
absconded. He afterwards resided some years in Wadáy, where he
had drilled a handful of the sultan’s slaves, had come to this kingdom
to try his fortune, and was now about to be sent to Wadáy by the
sheikh of Bórnu, as a spy, to see if the prince of that country had still
any design of recommencing hostilities. From all persons of this
description the traveller may learn a great deal; and, intriguing
fellows as they generally are, and going from court to court
spreading reports everywhere, prudence requires that he should
keep on tolerably good terms with them.
Most interesting and instructive was a host of pilgrims from
different parts of Másena or Mélle, partly Fúlbe, partly Sónghay, who
having heard of the white man, and of his anxiety to collect
information respecting all parts of the continent, came repeatedly to
me to contribute each his share. I used to regale them with coffee,
while they gave me ample opportunities of comparing and testing
their statements. The most interesting and best informed amongst
them, were Bu-Bakr, a native of Hamdalláhi, the capital of the sheikh
(sekho) Ahmedu ben Ahmedu, who, having made a pilgrimage to
Mekka, had long resided in Yeman, and was now returning
homeward with a good deal of knowledge; and another cheerful and
simple-hearted old man from Sá on the Ísa or Niger, between
Hamdalláhi and Timbúktu. Indeed, as the report of Ahmed bel Mejúb
about Ádamáwa had confirmed me in my determination to sacrifice
everything in order to visit that country as soon as possible, so the
manifold information of these people with respect to the countries on
the middle course of the so-called Niger excited in me a most ardent
desire to execute the design, previously but vaguely entertained, of
accomplishing also a journey westward to Timbúktu.
Among my Bórnu friends at this time, the most instructive were
Shitíma Makarémma and Ámsakay. The former, who had been a
courtier under the old dynasty, and who had saved his life by his
intrigues, was a very intelligent old man, but an acknowledged rascal
to whom unnatural vices, which seem in general entirely unknown in
these regions, were imputed. Nevertheless he was the only man who
was master of all the history of the old dynasty; and he spoke the
Kanúri language with such exquisite beauty as I have never heard
from anybody else. He had two very handsome daughters, whom he
succeeded in marrying, one to the vizier and one to his adversary,
ʿAbd eʾ Rahmán; but in December 1853 he was executed, together
with the vizier, but on totally different grounds, as having long
forfeited his life. Quite a different sort of man was Ámsakay, a simple
Kánemma chief, who has been represented in one of my sketches.
He had formerly distinguished himself by his expeditions against the
Búdduma, till those enterprising islanders succeeded in conciliating
him by the gift of one of their handsome daughters for a wife, when
he became half settled amongst them.
I had also some interesting pagan instructors, among whom I will
only mention Agíd Búrku, a very handsome youth, but who had
undergone the horrible process of castration. The abolition of this
practice in the Mohammedan world ought to be the first object of
Christian governments and missionaries, not merely on account of
the unnatural and desecrated state to which it reduces a human
being, but on account of the dreadful character of the operation itself,
which, in these countries at least, is the reason why scarcely one in
ten survives it: With extreme delight Agíd Búrku dwelt upon the
unconstrained nudity in which his countrymen indulged, and with
great naïveté described a custom of the Pagans, which is identical
with a custom of the civilized Europeans, but is an abomination in
the eyes of every Mohammedan. He had wandered about a good
deal in the southern provinces of Bagírmi and Wadáy, and gave me
the first information about the interesting mountain-group near
Kénga Matáya.
 But I must principally dwell upon my relations to the vizier el Háj
Beshír ben Ahmed Tiráb, upon whose benevolent disposition the
whole success of the mission depended, as he ruled entirely the
mind of the sheikh, who was more sparing of words, and less
intelligent. Mohammed el Beshír, being the son of the most influential
man in Bórnu after the sheikh, enjoyed all the advantages which
such a position could offer for the cultivation of his mind, which was
by nature of a superior cast. He had gone on a pilgrimage to Mekka
in the year 1843, by way of Ben-Gházi, when he had an opportunity
both of showing the Arabs near the coast that the inhabitants of the
interior of the continent are superior to the beasts, and of getting a
glimpse of a higher state of civilization than he had been able to
observe in his own country.
Having thus learned to survey the world collectively from a new
point of view, and with an increased eagerness after everything
foreign and marvellous, he returned to his native country, where he
soon had an opportunity of proving his talent, his father being slain in
the unfortunate battle at Kúsuri, and Sheikh ʿOmár, a fugitive in his
native country, having much need of a faithful counsellor in his
embarrassed situation. The sheikh was beset by a powerful and
victorious host, encamping in the largest of the towns of his kingdom,
while the party of the old dynasty was rising again, and not only
withdrawing from him the best forces wherewith to face the enemy,
but threatening his very existence, at the same time that a brother
was standing in fierce rivalry to him at the head of a numerous army.
Sheikh ʿOmár was successful, the host of Wadáy was obliged to
withdraw, and, abandoning the purpose for which they had come,
namely, that of re-establishing the old dynasty, commenced a difficult
retreat of many hundred miles at the beginning of the rainy season;
the partisans of the old dynasty were entirely crushed, the last prince
of that family slain, the residence of the sultans levelled to the
ground, and even the remembrance of the old times was almost
effaced. There remained to be feared only his brother ʿAbd eʾ
Rahmán. ʿAbd eʾ Rahmán was a good soldier, but a man of a very
loose and violent character. When a youth he had committed all
sorts of violence and injustice, carrying off young brides by force, to
indulge his passions: he was besides a man of little intelligence. But
being but a few months younger than ʿOmár, he thought himself
equally entitled to the succession; and if once admitted into a high
position in the empire, he might be expected to abuse his influence
on the very first opportunity.
Sheikh ʿOmár, therefore, could not but choose to confide rather in
the intelligent son of his old minister, the faithful companion in the
field and counsellor of his father, than in his own fierce and jealous
brother; and all depended upon the behaviour of Háj Beshír, and
upon the discretion with which he should occupy and maintain his
place as first, or rather only minister of the kingdom. Assuredly his
policy should have been to conciliate, as much as possible, all the
greater “kokanáwa” or courtiers, in order to undermine the influence
of ʿAbd eʾ Rahmán, whom it might be wise to keep at a respectful
distance. But in this respect the vizier seems to have made great
mistakes, his covetousness blinding him to his principal advantages;
for covetous he certainly was—first, from the love of possessing, and
also in order to indulge his luxurious disposition, for he was certainly
rather “kamúma,” that is to say, extremely fond of the fair sex, and
had a harím of from three to four hundred female slaves.
In assembling this immense number of female companions for the
entertainment of his leisure hours, he adopted a scientific principle;
in fact, a credulous person might suppose that he regarded his harím
only from a scientific point of view;—as a sort of ethnological
museum—doubtless of a peculiarly interesting kind—which he had
brought together in order to impress upon his memory the
distinguishing features of each tribe. I have often observed that, in
speaking with him of the different tribes of Negroland, he was at
times struck with the novelty of a name, lamenting that he had not
yet had a specimen of that tribe in his harím, and giving orders at
once to his servants to endeavour to procure a perfect sample of the
missing kind. I remember, also, that on showing to him one day an
illustrated ethnological work in which he took a lively interest, and
coming to a beautiful picture of a Circassian female, he told me, with
an expression of undisguised satisfaction, that he had a living
specimen of that kind; and when, forgetting the laws of
Mohammedan etiquette, I was so indiscreet as to ask him whether
she was as handsome as the picture, he answered only with a smile,
at once punishing and pardoning my indiscreet question. I must also
say that, notwithstanding the great number and variety of the women
who shared his attention, he seemed to take a hearty interest in
each of them: at least I remember that he grieved most sincerely for
the loss of one who died in the winter of 1851. Poor Háj Beshír! He
was put to death in the last month of 1853, leaving seventy-three
sons alive, not counting the daughters, and the numbers of children
which may be supposed to die in such an establishment without
reaching maturity.
But to return to his political character. I said that he neglected to
attach to himself the more powerful of the courtiers, with whose
assistance he might have hoped to keep the rival brother of Sheikh
ʿOmár at some distance; indeed, he even alienated them by
occasional, and sometimes injudicious use of his almost unlimited
power, obliging them, for instance, to resign to him a handsome
female slave or a fine horse. If he had possessed great personal
courage and active powers, he might have mastered circumstances
and kept his post, notwithstanding the ill-will of all around him; but he
wanted those qualities, as the result shows: and yet, well aware of
the danger which threatened him, he was always on his guard,
having sundry loaded pistols and carbines always around him, upon
and under his carpet. Shortly before I arrived, an arrow had been
shot at him in the evening, while he was sitting in his courtyard.
I have peculiar reason to thank Providence for having averted the
storm which was gathering over his head during my stay in Bórnu,
for my intimacy with him might very easily have involved me also in
the calamities which befell him. However, I repeat that altogether he
was a most excellent, kind, liberal, and just man, and might have
done much good to the country, if he had been less selfish and more
active. He was incapable, indeed, of executing by himself any act of
severity, such as in the unsettled state of a semi-barbarous kingdom
may at times be necessary; and, being conscious of his own
mildness, he left all those matters to a man named Lamíno, to whom
I gave the title of “the shameless left hand of the vizier,” and whom I
shall have frequent occasion to mention.
 I pressed upon the vizier the necessity of defending the northern
frontier of Bórnu against the Tuarek by more effectual measures than
had been then adopted, and thus retrieving, for cultivation and the
peaceable abode of his fellow-subjects, the fine borders of the
komádugu, and restoring security to the road to Fezzán. Just about
this time the Tuarek had made another expedition into the border-
districts on a large scale, so that Kashélla Belál, the first of the war
chiefs, was obliged to march against them; and the road to Kanó,
which I, with my usual good luck, had passed unmolested, had
become so unsafe that a numerous caravan was plundered, and a
well-known Arab merchant, the Sheríf el Gháli, killed.
I remonstrated with him on the shamefully neglected state of the
shores of the lake, which contained the finest pasture-grounds, and
might yield an immense quantity of rice and cotton. He entered with
spirit into all my proposals; but in a short time all was forgotten. He
listened with delight to what little historical knowledge I had of these
countries, and inquired particularly whether Kánem had really been
in former times a mighty kingdom, or whether it would be worth
retaking. It was in consequence of these conversations that he
began to take an interest in the former history of the country, and
that the historical records of Edrís Alawóma came to light; but he
would not allow me to take them into my hands, and I could only
read over his shoulders. He was a very religious man; and though he
admired Europeans very much on account of their greater
accomplishments, he was shocked to think that they drank
intoxicating liquors. However, I tried to console him by telling him
that, although the Europeans were also very partial to the fair sex,
yet they did not indulge in this luxury on so large a scale as he did,
and that therefore he ought to allow them some other little pleasure.
He was very well aware of the misery connected with the slave-
trade; for on his pilgrimage to Mekka, in the mountainous region
between Fezzán and Ben-Gházi he had lost, in one night, forty of his
slaves by the extreme cold, and he swore that he would never take
slaves for sale, if he were to travel again. But it was more difficult to
make him sensible of the horrors of slave-hunting, although, when
accompanying him on the expedition to Músgu, I and Mr. Overweg
urged this subject with more success, as the further progress of my
narrative will show. He was very desirous to open a commerce with
the English, although he looked with extreme suspicion upon the
form of articles in which the treaty was proposed to be drawn up; but
he wished to forbid to Christians the sale of two things, viz. spirituous
liquors and bibles. He did not object to bibles being brought into the
country, and even given as presents; but he would not allow of their
being sold. But the difficulties which I had to contend with in getting
the treaty signed will be made more conspicuous as my narrative
proceeds.
The most pressing matter which I had with the vizier in the first
instance, after my arrival, was to obtain some money, in order to
settle, at least partly, the just claims of the late Mr. Richardson’s
servants, and to clear off debts which reflected little credit on the
Government which had sent us. I could scarcely expect that he
would lend me the money without any profit, and was therefore glad
to obtain it at the rate of 1000 cowries, or kúngona as they are called
in Bórnu, for a dollar, to be paid in Fezzán; and I lost very little by the
bargain, as the creditors, well aware of the great difficulty I was in,
and acknowledging my desire to pay them off, agreed to receive for
every dollar of the sum which they claimed, only 1,280 cowries, while
in the market the dollar fetched a much higher price. Indeed it was
most grateful to my feelings to be enabled, on the 13th of April, to
distribute among the eight creditors 70,000 shells; and it was the
more agreeable, as the more arrogant among them, seeing my
extreme poverty, had assumed a tone of great insolence towards
me, which I found it difficult to support in silence. Being now relieved
a little in circumstances, I immediately rid myself of the carpenter, the
grandiloquent Son of Jerusalem, and sent him away. He died on the
road before reaching Múrzuk—a fact which the natives attributed to
the curse which I had given him for having stolen something from my
house.
My household now became more comfortable. Already, on the
10th of April, late in the evening, I had removed my quarters from the
large empty courtyard in the eastern town, or bílla gedíbe, to a small
clay house in the western, or bílla futébe. This dwelling consisted of